The health authorities have insisted
that the monovalent vaccines against measles, mumps and rubella
would not be made available in the United Kingdom. By doing so,
they have effectively forced parents who had serious concerns
about the MMR vaccine not to vaccinate their children
altogether. As vaccination rates fell and the threat of measles
outbreaks became real, the health authorities blamed Andrew
Wakefield and his research. Obviously no one mentions the fact
that Dr. Wakefield has always supported measles, mumps and
rubella vaccination of toddlers and that he has only suggested
that the monovalent vaccines be made available, alongside the
MMR vaccine, just to give parents a choice.

Dr. Simon Murch in a recent
interview introduced the threat of a rubella outbreak and the
resulting Congenital Rubella Syndrome (CRS) cases in his support
of the MMR vaccine. This represents a whole new front. It is
more than likely that the health authorities will now find a
poor family that has been devastated by having a child with CRS
to demonstrate how sad this disease is. Having cared for these
children, I can testify that CRS is a terrible disease and that
we must do everything we can to prevent it. On the other hand,
autism is just as awful a disease and like CRS, it destroys the
child and the family. The only difference is that presently
autism in England must outnumber CRS by 5000 to 1
conservatively. So if journalists are going to be interviewing
CRS parents, it is only fair that they also write stories about
the equivalent number of families that have been destroyed by
regressive autism and who have witnessed their perfectly healthy
normal toddlers disappear. One must remember that in 2002 in
California (Population 34.5 millions), TEN new cases of autism
accessed services every day.

Had the monovalent vaccines been
made available 2 years ago as suggested by Dr. Wakefield and had
the single rubella vaccine been administered to every child in
the UK, ONE WHOLE YEAR after the single measles vaccine, the
vaccination rates of both measles and rubella would be at 95%
right now. Obviously the health authorities could have also
chosen a shorter waiting period. After all, the single vaccines
used to be administered every 3 months in the pre-MMR days.

Let's consider some statistics from the U.S. The following is
from the CDC's “Epidemiology and Prevention of
Vaccine-Preventable Diseases,” 5th Edition (1999)
starting on page 176. The editors of that issue were Atkinson,
W, Humison S, Wolfe C and Nelson R.

“ Rubella and congenital rubella syndrome
became nationally notifiable diseases in 1966. The largest
annual total of cases of rubella in the United States was in
1969, when 57,686 cases were reported (58 cases per 100,000
population). Following vaccine licensure in 1969, rubella
incidence fell rapidly. By 1983, fewer than 1,000 cases per
year were reported (<0.5 cases per 100,000 population). A
moderate resurgence of rubella occurred in 1990-1991, primarily
due to outbreaks in California (1990) and among the Amish in
Pennsylvania (1991).

Until recently there was no
predominant age group for rubella cases. From 1982 to 1992,
approximately 30% of cases occurred in each of three age
groups: < 5, 5-19, and 20-39 years. Adults > 40 years of age
typically accounted for < 10% of cases. However, since 1994,
persons 20-39 of age have accounted for more than half of the
cases. In 1997, this age group accounted for 77% of all
reported cases. Most persons with rubella in this age group
were born outside the United States, in areas where rubella
vaccine is not routinely given.

In the pre vaccine era, epidemics of
rubella occurred every 6-9 years, with the last major U.S.
epidemic occurring in 1964-1965. No large epidemics have
occurred since the vaccine was licensed for use in 1969….

CRS surveillance is maintained through
the National Congenital Rubella Registry which is managed by the
National; Immunization program. The largest annual total of
reported CRS cases to the Registry was in 1970 (67 cases). An
average of 5-6 CRS cases have been reported annually since 1980.

Although reported rubella activity has
consistently and significantly decreased since vaccine has been
used, the incidence of CRS has only paralleled the decrease in
rubella cases since the mid 1970's. The fall in CRS since the
mid-1970's was due to an increased effort to vaccinate
susceptible adolescents and young adults, especially women.

Rubella outbreaks are almost always
followed by an increase in CRS. Rubella outbreaks in California
and Pennsylvania in 1990-1991 resulted in 25 cases of CRS in
1990 and 33 cases in 1991. A provisional total of 9 CRS cases
were reported in 1997. The mothers of all these infant s were
born outside the United States, primarily in Latin America and
the Caribbean, where rubella vaccine is not routinely used.”

The population of the Unites
States was 248.5 million in 1990 and 281.4 million in 2000. The
population of the United Kingdom was about 57 million in 1990
and 59 million in 2000. Assuming that the population of the UK
is more than one fourth that of the USA and stipulating that the
incidence of rubella and CRS is about the same in the two
countries, then, it is likely that before the introduction of
the rubella vaccine, there may have been at most 13,000-14,000
cases of rubella and 15-16 cases of CRS in the UK in any year.
The 33 cases of CRS in one year (1991), the highest in the US
since the vaccine, would translate to 6 cases in one year in the
UK and the average of 6-7 cases per year in the US would
be an average of one to two cases in the United Kingdom; there
were 4 cases of CRS in The USA in 1995 and 2 in 1996. For the
record, I firmly believe that ONE case a year of CRS is
one too many.

The following statement is important:

“From 1982
to 1992, approximately 30% of cases occurred in each of three
age groups: < 5, 5-19, and 20-39 years…However, since 1994, persons 20-39 of age have accounted
for more than half of the cases. In 1997, this age group
accounted for 77% of all reported cases. Most persons with
rubella in this age group were born outside the United States,
in areas where rubella vaccine is not routinely given”.
Whatever the reason, it is alarming that rubella, a childhood
disease, is now occurring more frequently in susceptible women.
It can be argued that if the women in that group had contracted
rubella as children, when the disease is fairly benign, they
would have acquired solid lifetime immunity. This appears to be
supported by the fact that in 1969, when the rubella vaccine was
licensed, there were 57,686 cases of rubella (reported) and 62
(0.1%) cases of CRS while in 1997, there were 181 reported cases
of rubella and 9 (5%) cases of CRS.

A study from Greece by T.
Panagiotopoulos T. et al.
published in the British Medical Journal (BMJ
1999;319:1462-1467) reports that:

MMR has been administered to
children in Greece since 1975

In 1993, the incidence of
rubella in young adults was higher than in any other
recent year

That there were 25
serologically confirmed cases of CRS {24.6/100 000 live
births, largest since 1950) that year.

“With low vaccination
coverage, the immunizationof boys and girls aged 1 year against rubella
carries the theoreticalrisk of increasing the occurrence of
congenital rubella”
wrote the authors

On page 175 of the same CDC
publication quoted earlier, the authors state that presently
“Up to 85% of infants infected in the first trimester of
pregnancy will be found to be affected if followed after birth.”
It is not clear whether
the authors refer to CRS or to other less serious complications.
Older pediatricians, this one included, did not see 80-85% of
children whose mothers developed rubella in the first trimester
of pregnancy, come down with CRS. In the late 50s we believed
that incidence to be around 25% and we thought that even those
odds were awful.

The following comprehensive review of
rubella in pregnant Danish Women (1975-1984), by M. Mitsch, was
published in the Danish Medical Bulletin in March1987
(34:46-49). It is one of the largest studies ever done and it
also shows how just few years ago, the clinical picture was
different. Its results are summarized in the following table
from WAVES, the New Zealand vaccine review.

WAVES Vol. 11 No. 4 p. 21

RUBELLA RISKS FOR PREGNANT WOMEN

DANISH MEDICAL BULLETIN MARCH 1987

A study of pregnancy outcomes of 1346
women serologically identified with rubella between 1975 and
1984.

Group 1

Group 2

623 chose
abortion

672 chose to
continue pregnancy

113 lost to
follow-up

No further
data – assumed no foetal autopsies

559 total

35 aborted
spontaneously

4
stillbirths

Total foetal
deaths = 39 (6.97%)

623 deaths

520 live
births – cord samples taken for rubella testing.

111 had
rubella specific IgM (21.34% infection rate)

14 of those
were infected prior to 12 weeks and 7 of those had
serious malformations (6.3% of 111)

NOTE: The above table was
listed as a historical reference of the incidence of CRS in
Denmark between 1975 and 1984. It does not apply to present
times in the UK and the US. It is probable that, as mentioned,
CRS will occur proportionately more frequently now.

An argument one hears often is
that toddlers must be vaccinated because if they are not, they
can come down with rubella and infect their susceptible pregnant
mother or teacher. Clearly the best way to prevent that
dangerous situation is to make sure that the female adult
herself is immune not all the children around her.

Susceptible pregnant women in their critical first trimester
may be exposed not only to children but to infected adults and
especially healthcare workers. The following abstract of a study
by Dr. Walter Orenstein , now Chief of the Vaccine Immunization
Program at CDC describes such potential risks.

Rubella vaccine and susceptible hospital employees. Poor
physician participation. Orenstein WA, Heseltine PN,
LeGagnoux SJ, Portnoy BA serosurvey of 2,456 high-risk
employees of the Los Angeles County-University of Southern
California Medical Center showed that 345 (14%) were
susceptible to rubella. Of 197 seronegative personnel
followed up for participation in a vaccination program, 105
(53.3%) were vaccinated. However, only one of the 11 known
susceptible obstetrician-gynecologists was vaccinated.
Thirty-eight seronegative employees who were vaccinated with
RA 27/3 rubella vaccine were queried four to six weeks after
vaccination and compared with 32 unvaccinated seropositive
control subjects. Although the reaction rate was 50% among
vaccinees and 3% among control subjects, each vaccinee lost
only an average of 0.2 workdays compared with 0.1 workdays
for control subjects. The high rate of susceptibility to
rubella among hospital employees supports the need for
screening. Although vaccine reactions are common, they are
generally mild. Means must be found to ensure greater
employee acceptance of vaccine.
PMID: 7463660, UI: 81120098JAMA
1981 Feb 20;245(7):711-3

Although it is highly advisable
that all mothers be immune to rubella, maternal immunity does
not always guarantee that the fetus will not develop CRS:

“Two children developed
congenital rubella infection when their mothers had been proven
to be satisfactorily immunised against rubella before the
affected pregnancy. One child was severely affected with heart
lesions, brain damage, severe deafness, physical retardation,
cataracts and rubella retinopathy. The other child had
moderately severe sensorineural deafness and a mild reduction in
visual acuity due to rubella retinopathy”Bott LM, Eizenberg DH.

Aust
N Z J Ophthalmol 1991 Nov;19(4):291-3

“We report a case of a patient
who had a subclinical rubella infection in the first trimester
of pregnancy which resulted in the delivery of a baby suffering
from congenital rubella. Rubella virus vaccine, live attenuated
(Cendevax) vaccine had been administered to the mother nearly
three years before, with proven sero-conversion from a rubella
haemagglutination-inhibition titer of 1:10 to 1:80.”Bott LM, Eizenberg DH.
Med J Aust 1982 Jun 12;1(12):514-5

“A 2 1/2 year-old girl was
found to have congenital rubella syndrome. She presented with
microcephaly, mild developmental delay, partial sensorineural
deafness and cerebellar atrophy. Blood titers of rubella
hemagglutinin were 1/256 and 1/512 (exclusively IgG). She had
not had rubella, nor had she been immunized against it. The
mother had been immunized against rubella 4 years before her
pregnancy with this girl and 2 years later blood hemagglutinin
titers were 1/32 and 1/64. She was neither exposed to nor
suffered from rubella during the pregnancy” Miron D, On A,
Harefuah 1992 Mar 1;122(5):291-3

“No population studies have evaluated the effectiveness of
screening and vaccinating

susceptible individuals in
reducing the incidence of CRS. Of the 21 CRS cases reported in
the U.S. in 1990, 71% of the mothers had a positive serologic
test, while 43% gave a history of vaccination”Carolyn DiGuiseppi,
MD, MPH, US Preventive Services Task Force. January 1994

.
In Summary:

Rubella is a rather benign illness in childhood.

Rubella vaccination at an appropriate age should be
encouraged.

The administration of the single rubella vaccine, 3 or 6
months, after the measles monovalent vaccine was very well
accepted for years.

Resumption of that schedule may be welcome by those who
have MMR concerns.

The majority of parents can still request the MMR
vaccine for their children.